Effective 1 Dec 2023
Repeat Customers: Please check
changed address? **_____  changed email address? **______

old address: _____________________________________________________________

SAMPUBCO NEW ORDER FORM - SCANNED IMAGES or PDF WILL RECORDS

NOTICE! Please do not add more than 6 per order form.

Name (PLEASE PRINT):** _____________________________________________________

Email (REQUIRED!):** _______________________________________________________

Street/P.O. Box:** _________________________________________________________

City/State/ZipCode+4:** ____________________________________________________
(out of USA - City, Province, Country, Postal Code)
Order (do NOT alter the information as listed onsite in any way):

Name of Person:     Residence:  County of Record:  State, County # Vol, Page #
Example: DOE, JOHN  Anyplace    Anycounty          XX-50-35-80

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________

6. _________________________________________________________________________

Please check: Scanned Image _____ (OR) PDF _____
Cost:
Number of records: _______ X USD $10.00 = __________ if by PayPal/CreditCard/eCheck
(if paying by credit card, please email order and request credit card invoice.)
Email address is dsam52 at sampubco.com for sending this order as attachment and
for sending payment via PayPal.

Number of records: ________X USD $15.00 = ___________if by check

Do NOT staple or tape check to the order. PLEASE DO NOT COMBINE WITH
ANY OTHER TYPE OF RECORD!

Please try to save the order form in your computer, as plain text (ASCII) and
use it as attachment instead. PDFs are ok if not possible.

Make check out to:
SAMPUBCO

Mail to:
W DAVID SAMUELSEN
629 S HARMONY CT
Salt Lake City, UT 84102-3446

STOP! Please check and verify the accuracy of the information. Do NOT forget
to list "County of Record", which is listed at top of the index page the
indexed information is found on.